RAS Issues Symposium: An argument against heroic intervention

To operate, or not to operate—that is the question. Data show that in 2008, among Medicare beneficiaries in the final year of life, nearly one in three underwent a surgical procedure. Nearly one in five had surgery in the last month of life, and nearly one in 10 had surgery in the last week of life.1

Why do we operate on these patients? Does the availability of hospital beds influence the surgeon’s decision to operate more frequently? Perhaps, but the reasons surgeons operate are more complicated than these data would suggest. Interventions at the end of life are often deemed heroic, but this valor comes at great financial cost to society. The factors influencing the decision to operate near the end of life include economics, ethics, culture, and politics. Of these, I argue that culture plays the greatest role. We do what we do because of who we believe we are and because of what we value. Although we may be, at times, misguided, it is the established cultural frameworks of both the patient and the surgeon that provide the context for decision making.

The surgical culture is defined by decisive action, hard work, technical acumen, passionate advocacy for patients, and the gratification of direct physical attention to pathologic processes. In light of these tenets of the surgical mindset, is it any wonder that we often provide surgical intervention near the end of life? We act because we value our ability to provide the highest level of care to those who are dying of disease and who are often elderly.

Critics have attacked our culture of action, alleging that surgeons are people who “live to cut.” As professionals, though, we strive to operate only on those patients whom we think we can truly help. We are sometimes wrong, and it is our failure to accurately prognosticate that exposes our actions to criticism. If we could truly foresee who will die in the next week, month, three months, or year, we would likely not operate on patients we know undeniably carry a poor prognosis. Our appreciation for the influence of age on prognosis is evidenced by the fact that surgical interventions near the end of life are less common in patients older than the age of 80.2 Yet, understanding these risks and how they are influenced by our cultural values, we may still operate with futility. In addition, our society’s expectations influence patient and family wishes, and they may also push us to operate in difficult situations.

Death is inevitable—an absolute truth. Surgeons like to operate. We want to help people. Our training provides us with unique tools to intervene upon reversible, life-threatening pathology. Who do we think we are as surgeons, and what do patients expect of us? Are physicians or patients capable of fundamental cultural change?

American culture is complex. Whereas there are definite geographic, ethnic, and generational variations, we are united in our respect for autonomy, individualism, and risk taking.3,4 Thus, it is not surprising that most patients do not accept death without putting up a good fight. Often our patients view surgery as a weapon in an epic war against disease and death. Virtually every obituary contains some version of the line “…lost their battle with….” Indeed, death will always be the victor.

The fear of death is natural. The fight for life is admirable. Therefore, the push for intervention near the end of life is not driven by an administrative desire for monetary gain, but by a larger cultural view that denies mortality, refuses to accept inaction, and is affected by a professional culture that values action in the face of potential (even if vanishingly so) reversibility. We are asked to “do something” even if it may be an exercise in futility. In this way, our desire to help is transformed to serve the cultural needs of our patients, their families, and our profession.

If we are ever to succeed in decreasing the number and cost of interventions near the end of life, a major shift in our surgical culture and American culture as a whole is necessary. Our knowledge of factors affecting morbidity and mortality should provide us with tools to effectively influence the decision making of our patients. Discussions that better incorporate important factors, such as preservation of quality of life, would better address the needs of the patient and guide discussions with families about the geriatric surgical population.5 Numerous studies support the notion that people do not wish to die in the hospital, yet many patients meet this fate. Families are often not satisfied with the care we provide at the end of life, reflecting a disconnect between what we think families want and what their loved ones truly desire.6

We can treat many illnesses in the elderly, but as the body prepares to succumb to its ultimate fate, we must be honest, compassionate, and experienced in recognition and acceptance. Goal-oriented care should take priority, and we must lay down our tools. We must accept the inevitability of death and find the nobility in facing mortality with resignation, dignity, and without intervention. We must learn to accept and even value inaction. Our statistics will not convince hesitant families, but can provide a basis for meaningful discussion and a path to acceptance of fate without absolute knowledge. It is only through fundamental cultural change that we can address the unsustainability of our current system, which too often provides unnecessary and insufficient care for the elderly population.

Our role is to serve as sages, not seers. We may think we intervene out of love, but sometimes love is blind.